Supportive Care in Cancer: Febrile Neutropenia

Supportive Care of Cancer Patients: Febrile Neutropenia

• Topic: Febrile Neutropenia in Cancer Patients
• Definition: a single oral temperature of ≥38.3°C (101°F) or a temperature of ≥38.0°C (100.4°F) sustained for at least one hour
• Risk factors: Cancer patients receiving cytotoxic antineoplastic therapy, sufficient to negatively impact bone marrow and gastrointestinal mucosal development.
• Risk Factors (additional cause): Colonizing bacteria and/or fungi that translocate across intestinal mucosal surfaces.
• Risk assessment: The MASCC Risk-Index Score and CISNE Score/Model are used to determine the risk for medical complications.
• High-risk patients: Receive cytotoxic therapy causing severe neutropenia (ANC <500 cells/microL) for over 7 days. Clinically unstable (hypotension, altered mental status, hypoxia, or oliguria). Present with uncontrolled comorbidity. MASCC score < 21. CISNE score ≥3 (in patients with solid tumors).
• Low-risk patients: Chemotherapy-induced neutropenia (ANC <500 cells/microL) lasting ≤7 days, Clinically stable (no hypotension, altered mental status, hypoxia, or oliguria). No active uncontrolled comorbidities. MASCC score ≥21. CISNE score of 0 (in patients with solid tumors).
• Management and treatment of high-risk patients: Hospitalization, empirical antimicrobial treatment (giving anti-pseudomonas antibiotics like piperacillin/tazobactam, cefepime, imipenem, meropenem or ceftazidime), and further investigation (blood cultures.)
• Management and treatment of low-risk patients: Outpatient management, broad-spectrum oral antimicrobials (e.g., fluoroquinolone + clavulanate or clindamycin if patient has penicillin allergy).
• Investigations: Complete Blood Count (CBC), renal and liver function, coagulation screen, C-reactive protein, blood cultures, urinalysis and culture, stool microscopy and culture, skin lesion (aspirate/biopsy/swab), chest radiograph.
• Work-up steps: Use the MASCC score to detect the patient risk of febrile neutropenia (risk level >21=high risk).
• Additional Treatment: Administer aminoglycosides to cover gram-negative bacteria and vancomycin to cover gram-positive bacteria (MRSA) in specific cases of complications such as pneumonia, soft tissue infection, hemodynamically unstable state or catheter infections.

Prophylaxis

• Patients receiving aggressive induction chemotherapy regimens (leukemia), allogenic hematopoietic stem cell transplantation, profound and prolonged neutropenia (ANC <100) should receive prophylaxis
  • Antibiotics: fluoroquinolones (levofloxacin), antifungals (fluconazole, itraconazole, voriconazole, caspofungin), or antiviral agents (acyclovir).
  • Growth factors (G-CSF)

This quiz focuses on the critical aspects of febrile neutropenia in cancer patients, including its definition, risk factors, and assessment scores like the MASCC Risk-Index and CISNE Model. Understanding these elements is essential for providing effective supportive care during cancer treatment. Test your knowledge on how to identify and manage high-risk and low-risk patients.